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Marsh, Inc 8/24/2006 4:54 PM PAGE 8/008 Eastern Time Zone Workers' Compensation and Employers' Liability Policy Named Insured: Johnson Controls, Inc. Endorsement Number: AA Policy Number: WLRC44333879 WLRC44333880 - CA Policy Period:10 -1 -05 TO 10 -1 -06 Effective Date of Endorsement: 10 -1 -05 Issued by (Name of Insurance Company): Indemnity Insurance Company of North America and for CA: ACE American Insurance Company Insert the policy number. The remainder of the information of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. ...................................................................................................................................................................................... ............................... ...................................................................................................................................................................................... ............................... Person or Organization: If required by contract, City of Santa Ana, its officers, employees, agents, volunteers and representatives Job Description: 1N...:A...#.Y...E....R..:O...F....:O...l..1.R....:R...l ... ..M..T ... ....4....#.i..E..C...O...i..f.E...f..i..: ..F ..R...O...M..... Q?.f..M...E..R...S..........:::::::..........I....... ... ...:.:.:.:.:.:.:.:.:. : .:.:.:.:.:.:.:.:...:.:.:. : WC 00 03 13 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. 1NA t#T:::Ow :.. .M1`fh11NpiMNT Ci4LI�JINlki4: WC 04 03 06 Ed. 4 -84 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that required you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be —INCLUDED _% of the California workers' compensation premium otherwise due on such remuneration. Copyright 1982 -83, National Council on Compensation Insurance Authorized Agent